Value and Limitations of Urethrotech Catheterisation Device to Manage Difficult Urethral Catheterisation in Male Spinal Cord Injury Patients

Methods

We used a Urethrotech catheterisation device in 57 male patients with spinal cord injury, in whom urethral catheterisation was unsuccessful or previous catheterisation was difficult.

Results

Urethrotech catheter could be inserted in 51 patients. No patient developed urinary tract infection. In one patient, the guidewire could not be introduced into the bladder, and a coude Foley catheter was inserted. In two patients, the guidewire was inserted into the bladder, but a 16 CH catheter could not be advanced over the guidewire. Emergency suprapubic cystostomy was performed in one case; in the other, urethral stricture was dilated; a size 12 CH catheter was inserted. In three patients, the guidewire curled back into the urethra because of severe spasm of the urethral sphincter. Catheterisation with a Tiemann catheter was successful after administration of diazepam and/or stretching of the anal sphincter by another health professional, which caused reflex relaxation of the urethral sphincter. Complications of Urethrotech catheterisation included urethral bleeding, haematuria, pain, doubling back of the guidewire due to spasm of the urethral sphincter or from an empty bladder. We adopted variations in technique, eg filling the bladder with saline prior to catheterisation when feasible, insertion of the guidewire by the side of the old catheter, use of Tiemann tip catheters, administration of antibiotics, diazepam to control spasms, nifedipine to control autonomic dysreflexia, analgesics, stretching of the anal sphincter to induce reflex relaxation of the urethral sphincter, urgent imaging studies to confirm correct positioning of the catheter, omitting anticoagulants and monitoring patients, who developed bleeding.

Conclusion

Use of Urethrotech in spinal injury patients warranted adaptations to the technique, which required expertise, experience, and backup facilities. To ensure patient safety, Urethrotech catheter should be used in a hospital setting, and by medical personnel with experience in the management of spinal cord injury patients.

Thoracic spinal cord injury after surgical removal of a ruptured cerebellar arteriovenous malformation in a patient in the Concorde position: illustrative case

BACKGROUND

Thoracic spinal cord injury after posterior cranial fossa surgery in younger patients is a rare complication. There have been reports of this complication in tumor and spine fields but not in vascular surgery.

OBSERVATIONS

A 22-year-old-man experienced cerebellar arteriovenous malformation rupture, and the malformation was surgically removed with the man in the Concorde position. After surgery, the man had severe paraplegia, and a thoracic spinal cord injury was diagnosed.

LESSONS

In younger patients, cervical hyperflexion in the Concorde position can cause thoracic spinal cord injury even in surgery for cerebrovascular disease.

Acute Paraplegia Caused by Spinal Epidural Empyema Following Infectious Cellulitis of the Hand: Case Report and Literature Review

Background  Spinal epidural abscess is a rare but serious condition that can cause spinal cord compression and neurological deficits. Case Description and Methods  The article reports a case of a 31-year-old patient who presented with an infectious cellulitis in the left hand, which progressed to a spinal epidural abscess. The diagnosis was confirmed by clinical examination and magnetic resonance imaging. Treatment involved laminectomy, after which the patient had complete recovery of neurological deficits. This article is a case report with a literature review. Patient data and images were collected by the researchers who participated in the patient's care. The literature was reviewed by one of the researchers based on the search for articles in the PubMed database. For the research, the following keywords were inserted: "Spinal epidural empyema," "Spinal epidural abscess." Conclusion  Spinal epidural abscess is often underdiagnosed, which can lead to delays in treatment and serious complications. The relationship between cellulitis and spinal epidural abscess may be related to the spread of infection through the lymphatic or blood system.

Which PDE5 inhibitor is the most effective in the treatment of erectile dysfunction in men with spinal cord injury? A systematic review and network meta-analysis

BACKGROUND

Phosphodiesterase 5 inhibitors (PDE5i) are the first-line drugs for erectile dysfunction (ED) but differences among available molecules should drive therapy personalization. Choosing one PDE5i over another is a challenge in men with spinal cord injury (SCI), as the evidence of efficacy for each molecule is derived from few studies and comparative "head-to-head" trials are lacking.

OBJECTIVE

To assess the efficacy of the different PDE5i for SCI-related ED with a network meta-analysis (NMA) approach.

MATERIALS AND METHODS

Databases from PubMed, Web of Science, Scopus, and Cochrane Library were checked for randomized controlled trials (RCTs) comparing any PDE5i to each other or placebo in men with traumatic SCI lasting ≥6 months. Data were incorporated in a random-effect NMA, where treatments' efficacy was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

The 10 RCTs included provided information about 1,492 men with ED due to traumatic SCI. Intervention arms included sildenafil, tadalafil, and/or vardenafil. Overall, at the pairwise meta-analysis, PDE5i were four times more effective than placebo in improving erectile function (risk ratio: 4.13, 95% CI: 2.76, 6.19). The comparative analysis from NMA revealed that tadalafil was associated with the highest SUCRA value (81%), followed by vardenafil (68%) and sildenafil (49%).

DISCUSSION AND CONCLUSION

Within the grading of comparison network, tadalafil appeared to be the best PDE5i in the treatment of SCI-related ED. Further focused studies are warranted to confirm these findings and define optimal doses and duration of therapy.

Neuromodulation's Role in Functional Restoration in Paraplegic and Quadriplegic Patients

Neuromodulation is an alternative, minimally invasive treatment option that, at times, is used as a last resort for chronic pain conditions that are often refractory to other treatment modalities. Moreover, it offers promising prospects for individuals grappling with the formidable challenges posed by paraplegia and quadriplegia resulting from spinal cord injuries. This review article provides a comprehensive assessment of current treatment modalities specifically tailored for paraplegic and quadriplegic patients. We aim to evaluate the existing surgical and non-surgical interventions while delving into the role of neuromodulation in the restoration of function for individuals afflicted with these debilitating conditions. Additionally, we review the efficacy, limitations, and comparative outcomes of diverse treatment strategies available for the management of paraplegia and quadriplegia. Emphasizing the critical need for effective interventions beyond the initial 24 h surgical window, we elucidate the challenges associated with conventional therapies and their limited success in achieving comprehensive functional restoration. Central to this review is an in-depth exploration of neuromodulation's transformative potential in ameliorating the deficits caused by spinal cord injuries. With a particular focus on spinal cord stimulation (SCS), we analyze and compare the outcomes of neuromodulation modalities and traditional treatment regimens, shedding light on the promising strides made in fostering sensory perception, motor function, and patient satisfaction.

Spinal Cord Infarction Thrombolysed at Seven Hours: A Case Report and Review of Literature

We report a case of acute spinal cord infarction treated with intravenous (IV) thrombolysis at seven hours from symptom onset. Nineteen previously thrombolysed cases are reviewed. The patient underwent a clinical assessment, followed by an MRI of the spine. He was thrombolysed with a recombinant tissue plasminogen activator. Neurological severity was assessed at presentation and 24 hours using the National Institute of Health Stroke Scale (NIHSS), and disability at three months was evaluated using a modified Rankin scale (mRS). A middle-aged man presented with acute-onset paraplegia (NIHSS 9). MRI with T2-weighted sagittal, axial, and diffusion-weighted images showed hyperintensity from D10 to LI vertebral levels. He was thrombolysed at 428 minutes, leading to mild clinical improvement at 24 hours (NIHSS 7). At three months, he could walk with support (mRS 3). Nineteen cases of acute spinal cord infarction treated with IV thrombolysis have been reported. Clinical outcome at three months is available for 16 patients: seven (44%) had a good outcome (mRS 0-2); this is the first reported case of spinal cord infarction treated with thrombolysis at seven hours. Clinical trials to confirm the efficacy and safety of thrombolysis in spinal cord infarcts are needed.

Psychosocial reintegration post-traumatic spinal cord injury in Rwanda: An exploratory study

Background

Traumatic spinal cord injury (TSCI) survivors are confronted by both physical and psychosocial barriers when returning to their communities. Therefore, reintegration is an important aspect of their journey back into social life.

Objectives

To assess psychosocial reintegration after TSCI in Rwanda.

Method

All community-dwelling adults who were registered in the previous epidemiological study were recruited and injury characteristics questionnaire and the Sydney Psychosocial Reintegration Scale version 2 (SPRS-2) were used to collect data through a telephone interview.

Results

The study traced 58 participants, 77.6% (n = 45) were male and 56.9% (n = 33) were categorised with paraplegia. Overall, the results show poor community reintegration. The SPRS-2 and domain mean (SD) scores were: overall SPRS-2 of 20.95 (11.56), occupational activity (OA) of 3.68 (4.31), interpersonal relationship (IR) of 7.11(4.31) and living skills (LS) of 7.43 (5.32). Gender significantly influenced overall SPRS-2 (p = 0.011) and two domains: OA (p = 0.005) and LS (p = 0.012). Level of injury was significantly associated with an OA domain score of SPRS-2 (p = 0.002). Gender explained 29% of the variance in the LS domain of SPRS-2, with males reporting better psychosocial reintegration.

Conclusion

Gender strongly predicted psychosocial reintegration following a TSCI, which is an indication of the role of social support.

Clinical Implications

Traumatic SCI rehabilitation should be holistic to help prepare the person to return to the community. There should be an assessment of an individual's readiness to return to the community before discharge from the hospital.

Randomized Controlled Trial of Durotomy as an Adjunct to Routine Decompressive Surgery for Dogs With Severe Acute Spinal Cord Injury

Although many interventions for acute spinal cord injury (SCI) appear promising in experimental models, translation directly from experimental animals to human patients is a large step that can be problematic. Acute SCI occurs frequently in companion dogs and may provide a model to ease translation. Recently, incision of the dura has been highlighted in both research animals and human patients as a means of reducing intraspinal pressure, with a view to improving perfusion of the injured tissue and enhancing functional recovery. Observational clinical data in humans and dogs support the notion that it may also improve functional outcome. Here, we report the results of a multi-center randomized controlled trial of durotomy as an adjunct to traditional decompressive surgery for treatment of severe thoracolumbar SCI caused by acute intervertebral disc herniation in dogs. Sample-size calculation was based on the proportion of dogs recovering ambulation improving from an expected 55% in the traditional surgery group to 70% in the durotomy group. Over a 3.5-year period, we enrolled 140 dogs, of which 128 had appropriate duration of follow-up. Overall, 65 (51%) dogs recovered ambulation. Recovery in the traditional decompression group was 35 of 62 (56%) dogs, and in the durotomy group 30 of 66 (45%) dogs, associated with an odds ratio of 0.643 (95% confidence interval: 0.320-1.292) and z-score of -1.24. This z-score indicates trial futility to reach the target 15% improvement over traditional surgery, and the trial was terminated at this stage. We conclude that durotomy is ineffective in improving functional outcome for severe acute thoracolumbar SCI in dogs. In the future, these data can be compared with similar data from clinical trials on duraplasty in human patients and will aid in determining the predictive validity of the "companion dog model" of acute SCI.

Perspectives of wheelchair users with chronic spinal cord injury following a walking program using a wearable robotic exoskeleton

PURPOSE

To examine the perspectives of wheelchair users with spinal cord injury (WUSCI) regarding their participation in a 16-week walking program using a wearable robotic exoskeleton (WRE); and explore concerns and expectations regarding potential use of this device and intervention in the context of a home or community-based adapted physical activity program.

METHOD

Semi-structured interviews were conducted using a narrative research, 3 weeks post-intervention. Thematic analysis resulted in 6 themes and 21 subthemes.

RESULTS

Seven men and 4 women aged between 32 and 72 years were interviewed; 8 of them had a complete SCI. After the walking program, WUSCI reported positive psychological aspects (having fun and motivation) and experiencing improvements in physical aspects (strength, endurance, balance and flexibility, blood circulation and intestinal transit). The structural aspects of the WRE device were acceptable in a lab with research personnel (appearance, size, weight, and comfort). Participants had concerns about safety on uneven surfaces, and possibility of falling. They expressed the desire to use the WRE for more life habits than just walking.

CONCLUSION

This is the first study in which WUSCI report that the WRE should be implemented in initial rehabilitation. Lack of availability for community use after rehabilitation remains a concern.

Apprehension of Paraplegia after Undergoing Spinal Anesthesia in the Central Region Population of Saudi Arabia: A Cross-Sectional Study

Aim

The aim of the present study was to determine the prevalence of paraplegia-related fear in spinal anesthesia among the general population in the central region of Saudi Arabia.

Materials and Methods

A total of 371 participants were given a pretested, precoded, questionnaire was used to collect data to assess the prevalence of fear of paraplegia in spinal anesthesia. The questionnaire contained questions to assess variables like the extent of fear, causes, gender preponderance, any false information about paraplegia in spinal anesthesia, and complications experienced after receiving spinal anesthesia.

Results

It was noted that 80.1% of the respondents were familiar with the term spinal/regional/epidural anesthesia. Forty one point eight percent of the respondents their reference of knowledge about regional anesthesia was family of friends. Thirteen point nine percent of the responses were paralysis, 8.2% of the responses were feeling of pain during the operation, and 7.9% of the responses were nausea or vomiting.

Conclusion

The present study revealed that the participants exhibited a certain degree of apprehension stemming from their inadequate understanding and awareness regarding spinal anesthesia.

Long-term debridement effect of denervated large sacrococcygeal pressure injury: A case report

RATIONALE

Complicated pressure injury in paraplegic patients is common and difficult to manage. Previous case studies have documented short-term management; however, little is known regarding suitable approaches to long-term clearing of extensive pressure injury in the sacrococcygeal area under denervation.

PATIENT CONCERNS

A 53-year-old man was bedridden for 1.5 years owing to cervical vertebral fracture-dislocation (C5-C6), resulting in extensive sacrococcygeal pressure injury.

DIAGNOSES

On admission, he presented with the injury complicated by infection (stage IV necrosis), and his vital signs were unstable.

INTERVENTIONS

The infection was treated with a range of antibiotics, including clindamycin phosphate, metronidazole, cefoperazone sodium, and sulbactam sodium. Debridement of the pressure injury was performed, helping remove the necrotic tissue and stimulate tissue regeneration.

OUTCOMES

The patient was discharged after 88 days of hospitalization. The extent of the pressure injury at discharge was reduced compared with that at admission. At 4-month follow-up, the injury was nearly healed, with no signs of any further complications.

LESSONS

This case study suggests that wound debridement is a cost-effective and clinically efficacious approach to long-term complicated pressure injury management.

Digital psychosocial interventions for individuals with spinal cord injury: a scoping review

Objective

To provide an overview of the digital mental health care landscape for individuals with spinal cord injury (SCI).

Methods

PubMed, PsycInfo, and PSYNDEX were searched for articles meeting the following criteria: (1) article written in English or German; (2) digital psychosocial intervention; (3) SCI only; (4) treatment of individuals with SCI and not their relatives or caregivers. Records were screened by title and abstract and records meeting the inclusion criteria were obtained for full text screening. The references of identified articles were screened to find further relevant articles. The literature search was updated before submission. Risk of Bias was assessed by using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and a narrative synthesis was conducted.

Results

Ten randomized-controlled trials (RCT) and ten non-randomized-controlled trials were identified and compared in this review, evaluating twelve internet- and mobile-based interventions, five smartphone apps, and three virtual reality applications. The interventions were primarily used as stand-alone aftercare programs. While some were not based on any theory, cognitive behavioral therapy mostly served as the theoretical basis for the online interventions. The extent of human support also varied greatly between the studies. The number of intervention modules ranged between 2 and 72. There were also major differences in outcome variables and effects. A meta-analytical evaluation of the data was not conducted due to heterogeneity of studies.

Conclusion

Digital applications to promote the psychosocial health of individuals with SCI are an emerging field of research with many treatment approaches still to come. First high quality RCT studies report promising results. Unfortunately, not all studies are of high quality or the interventions have been insufficiently adapted to the needs of people with SCI. Therefore, more research is needed to further develop applications, and to generalize and test the effects found in the long term.

Activated Human Adipose Tissue Transplantation Promotes Sensorimotor Recovery after Acute Spinal Cord Contusion in Rats

Traumatic spinal cord injuries (SCIs) often result in sensory, motor, and vegetative function loss below the injury site. Although preclinical results have been promising, significant solutions for SCI patients have not been achieved through translating repair strategies to clinical trials. In this study, we investigated the effective potential of mechanically activated lipoaspirated adipose tissue when transplanted into the epicenter of a thoracic spinal contusion. Male Sprague Dawley rats were divided into three experimental groups: SHAM (uninjured and untreated), NaCl (spinal cord contusion with NaCl application), and AF (spinal cord contusion with transplanted activated human fat). Pro-inflammatory cytokines (IL-1β, IL-6, TNF-α) were measured to assess endogenous inflammation levels 14 days after injury. Sensorimotor recovery was monitored weekly for 12 weeks, and gait and electrophysiological analyses were performed at the end of this observational period. The results indicated that AF reduced endogenous inflammation post-SCI and there was a significant improvement in sensorimotor recovery. Moreover, activated adipose tissue also reinstated the segmental sensorimotor loop and the communication between supra- and sub-lesional spinal cord regions. This investigation highlights the efficacy of activated adipose tissue grafting in acute SCI, suggesting it is a promising therapeutic approach for spinal cord repair after traumatic contusion in humans.

Can the Initial Parameters of Functional Scales Predict Recovery in Patients with Complete Spinal Cord Injury? A Retrospective Cohort Study

Regaining greater independence in performing daily activities constitutes a priority for people with tetraplegia following spinal cord injury (SCI). The highest expectations are connected with the improvement of hand function. Therefore, it is so important for the clinician to identify reliable and commonly applicable prognostic factors for functional improvement. The aim of this study was to conduct an analysis to assess the impact of initial functional factors on the clinical improvement in patients during early neurological rehabilitation (ENR). This study assessed 38 patients with complete SCI aged 17-78 who underwent ENR in 2012-2022. The analysis included the motor score from the AIS (MS), the Barthel Index (BI) and the SCIM scale values at the beginning of the ENR program and after its completion. During ENR, patients achieved a statistically significant improvement in MS, BI and SCIM. The initial MS and the level of neurological injury constituted the predictors of functional improvement during ENR. Significant statistical relationships were observed primarily in the correlations between the initial MS and BI, and the increase in the analyzed functional scales of SCI patients. Higher initial MS may increase the chances of a greater and faster functional improvement during ENR.

Exercises With Optimal Scapulothoracic Muscle Activation for Individuals With Paraplegia

Background

Individuals with paraplegia and coexisting trunk and postural control deficits rely on their upper extremities for function, which increases the risk of shoulder pain. A multifactorial etiology of shoulder pain includes "impingement" of the supraspinatus, infraspinatus, long head of the biceps tendons, and/or subacromial bursa resulting from anatomic abnormalities, intratendinous degeneration, and altered scapulothoracic kinematics and muscle activation. Targeting serratus anterior (SA) and lower trapezius (LT) activation during exercise, as part of a comprehensive plan, minimizes impingement risk by maintaining optimal shoulder alignment and kinematics during functional activities. To prevent excessive scapular upward translation, minimizing upper trapezius (UT) to SA and LT activation is also important.

Objectives

To determine which exercises (1) maximally activate SA and minimize UT:SA ratio and (2) maximally activate LT and minimize UT:LT ratio.

Methods

Kinematic and muscle activation data were captured from 10 individuals with paraplegia during four exercises: "T," scaption (sitting), dynamic hug, and SA punch (supine). Means and ratios were normalized by percent maximum voluntary isometric contraction (MVIC) for each muscle. One-way repeated measures analysis of variance determined significant differences in muscle activation between exercises.

Results

Exercises were rank ordered: (1) maximum SA activation: SA punch, scaption, dynamic hug, "T"; (2) maximum LT activation: "T," scaption, dynamic hug, SA punch; 3) minimum UT:SA ratio: SA punch, dynamic hug, scaption, "T"; and (4) minimum UT:LT ratio: SA punch, dynamic hug, "T," scaption. Exercise elicited statistically significant changes in percent MVIC and ratios. Post hoc analyses revealed multiple significant differences between exercises (p < .05).

Conclusion

SA punch produced the greatest SA activation and lowest ratios. Dynamic hug also produced optimal ratios, suggesting supine exercises minimize UT activation more effectively. To isolate SA activation, individuals with impaired trunk control may want to initiate strengthening exercises in supine. Participants maximally activated the LT, but they were not able to minimize UT while upright.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score

Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.

Preparing the spinal cord - priming or preconditioning? A systematic review of experimental studies

Objectives. Paraplegia is devastating complication associated with thoracic and thoracoabdominal aortic aneurysm repair. Vast evidence has been gathered on pre-, peri- and postoperative protective adjuncts aiming to minimize spinal cord ischemia. This review focuses on the pretreatment phase of open surgical or endovascular aortic procedures and gathers the experimental data on the interventional preconditioning and priming methods that increase the spinal cord ischemic tolerance. Design. By the start of March 2021, a systematic review was performed in PubMed, Scopus and Web of Science core collection to identify the articles that reported (i) either an ischemic preconditioning, remote ischemic preconditioning or priming method prior to (ii) experimental spinal cord ischemia performed in endovascular or open surgical fashion mimicking either thoracic, abdominal or thoracoabdominal aortic aneurysm procedures. (iii) The outcomes were reported via neurological, motor-evoked potential, somatosensory-evoked potential, histopathological, immunohistochemical, physiological analysis, or in different combinations of these measurements. Results. The search yielded 7802 articles, and 57 articles were included in the systematic review. The articles were assessed by the evaluated species, the utilized pretreatment, the measured protective effects, and the suggested underlying mechanisms. Conclusions. The reviewed articles showed several possible mechanisms in ischemic and remote ischemic preconditioning for prevention of spinal cord ischemia. The main suggested method for priming was arteriogenetic stimulus. Future studies should confirm these hints of arteriogenetic stimulus with more precise quantification of the protective recruitment process.

Development and Validation of Wheelchair-Based Yoga Module for Individuals with Paraplegia

Spinal cord injury causes temporary or permanent loss of motor, sensory, or autonomic functions, leading to long-term impairments that are not only confined to physical attributes but also restrict individuals' participation in major domains of life. Around 60%-80% of individuals with spinal cord injuries depend on a wheelchair for mobility. Numerous studies have reported yoga's beneficial role in alleviating spinal cord injury symptoms; however, a validated wheelchair-based yoga module was unavailable. Thus, the present study aimed to develop and validate a wheelchair-based yoga module that comprises a printed protocol for individuals with paraplegia. The study was conducted in four phases: The first three phases were the steps for the formulation of a wheelchair-based yoga module, and in the last phase the content validity of the designed module was determined by a panel of 10 experts, who were asked to rate the preliminary module for its necessity and relevance using a Likert scale. A total of 17 yoga practices with high content validity were included in the final wheelchair-based yoga module, and 10 practices with lower content validity were excluded from the designed module. Data analysis revealed the mean content validation index of the designed module to be 0.81. This study concludes that the formulated wheelchair-based yoga module is valid for individuals with paraplegia. However, future studies need to be conducted to determine the protocol's feasibility and effectiveness.

Burden of Cardiovascular Risk in Individuals With Spinal Cord Injury and Its Association With Rehabilitation Outcomes: Results From the Swiss Spinal Cord Injury Cohort

OBJECTIVES

The aims of the study are to determine the cardiovascular risk burden rehabilitation discharge and to explore the association between recovery during rehabilitation and cardiovascular disease risk profile.

METHODS

We included adults without cardiovascular disease admitted for rehabilitation. We evaluated rehabilitation outcomes on admission and discharge. Cardiovascular disease risk profile was assessed by Framingham risk score, high-density lipoprotein, and fasting glucose level.

RESULTS

We analyzed data from 706 participants (69.6% men) with a median age of 53.5 yrs. The median time since injury was 14 days, and the admission length was 5.2 months. Majority had paraplegia (53.3%) and motor incomplete injury (53.7%). One third of the cohort had high cardiovascular risk profile before discharge. At discharge, poorer anthropometric measures were associated with higher Framingham risk score and lower high-density lipoprotein levels. Individuals with higher forced vital capacity (>2.72 l) and peak expiratory flow (>3.4 l/min) had 0.16 mmol/l and 0.14 mmol/l higher high-density lipoprotein compared with those with lower respiratory function, respectively. Individuals with higher mobility score (>12.5) and functional independence score (>74) had 0.21 and 0.18 mmol/l higher high-density lipoprotein compared with those with lower scores.

CONCLUSIONS

There is high cardiometabolic syndrome burden and cardiovascular disease risk profile upon rehabilitation discharge. Higher respiratory function, mobility, and overall independence were associated with better cardiovascular disease risk profile, although with study design limitations and short follow-up. Future studies should explore whether rehabilitation outcomes could be used to prioritize screening.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon reading this journal article, the reader is expected to: (1) Determine the burden of cardiometabolic disease in the early phase of spinal cord injury (SCI); (2) Differentiate the proposed SCI cutoff for high-risk obesity from the able-bodied population; and (3) Increase physicians' acuity for detecting cardiometabolic disease in their practice.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Rehabilitation Towards Functional Independence in a Patient With Metastatic Carcinoma of Lung and Paraplegia: A Case Report

Lung cancer metastasis is a complex process. This case report describes a case of a 58-year-old man with carcinoma of the lung with bony metastasis to spine T9-T11 with the chief complaints of inability to move both lower limbs, breathlessness, and difficulty in bed mobility. Motor impairments may transpire in three different forms, which are paraplegia, hemiplegia, or quadriplegia. Functional electrical stimulation (FES) with body weight support treadmill training (BWSTT) is a widespread rehabilitation approach used to restore motor function of the lower limb and balance. This case report specifies the physiotherapeutic rehabilitation protocol, which includes dyspnea management, FES with BWSTT, proprioceptive neuromuscular facilitation, etc. for a patient undergoing physiotherapy The patient's occupational requirements and enhancement in executing daily living tasks were the focus of the physiotherapeutic rehabilitation. The outcomes used were the modified Medical Research Council (mMRC) grading of dyspnea and the Functional Independence Measure (FIM). We report a marked increment in muscle tone and strength, active range of motion (AROM), and significant enhancement in the individual's functional independence with physiotherapeutic protocol.

Idiopathic spinal cord herniation with postoperative paraplegia-A case report

Key clinical message

Spinal cord herniation is an uncommon diagnosis. There should be a high index of suspicion to diagnose spinal cord herniation when a patient presents with incomplete neurological deficits. Surgical repair of the hernia can have postoperative complications with new neurological deficits and they should be considered during the treatment.

Abstract

A 37-year-old male presented with insidious onset upper back pain and altered sensations of pain and temperature over the right half of the body below the nipple for 2 months. MRI of the thoracic spine showed an anterolateral defect (left) at the level of T2-T3 vertebra. The defect was covered by a dural graft and the wound was closed with a drain On the 3rd postoperative day, neurological weakness progressed to paraplegia. Patient was treated by exploration and decompression of the hematoma. The deficits were completely recovered at one-month follow-up. Patients with spinal cord herniation and neurologic deficits when treated timely have good outcomes.

Combined Effect of Pelvic Proprioceptive Neuromuscular Facilitation with Core Strengthening on Trunk Control, Balance, and Gait in Paraplegia

Spinal cord injury (SCI) has deleterious effects on quality of life and vocation. A partial or complete loss of sensory and motor functions below the site of injury is a potential clinical sign of SCI. Trunk and pelvic control are crucial for balance and gait to perform vocational tasks of daily living. In this case report, a 40-year-old male with traumatic incomplete paraplegia (AIS Grade C, neurological level T6) received 45 min of intervention per session, which included pelvic proprioceptive neuromuscular facilitation combined with core strengthening exercises 5 times a week for 4 weeks. Baseline and postassessments were done for trunk control with the trunk control test for SCI, balance with the Berg Balance Scale (BBS) and the SCI-functional ambulation inventory (SCI-FAI), and gait with the walking index for SCI II (WISCI). After 4 weeks of intervention, there were significant differences between baseline and postintervention scores on the trunk control test for SCI (16-18), WISCI (Level 1-2), SCI-FAI (03-06), and BBS (04-08). This is the first case report that enabled and promoted potentiate intervention to improve trunk control, balance, and gait in paraplegics. This outcome motivates additional research on its therapeutic potential and mechanism.

Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations

Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.

Minimally invasive staged segmental artery coil embolization (MIS2ACE) for spinal cord protection

Minimally invasive staged segmental artery coil embolization (MIS2ACE) is an emerging technology for priming of the paraspinous collateral network prior to open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Its safety and efficacy have been previously proven in various experimental settings and confirmed in numerous multicentric pilot studies for open and endovascular repair. MIS2ACE is safe and has the potential to decisively reduce the risk of postoperative paraplegia, the most devastating complication of open and endovascular TAAA repair, still affecting up to 20% of patients. Up to now, MIS2ACE has been clinically implemented with excellent results, and is currently being investigated in the international, multicenter, randomized controlled trial PAPAartis, funded by the German Research foundation, and the European Union. MIS2ACE can be performed under local anesthesia, enabling continuous monitoring of neurological function, and in case of clinical signs of imminent ischemia, preemptive interruption of the procedure. A thorough evaluation of preoperative computed tomography (CT) imaging for identification of open and accessible segmental arteries (SAs) is critical. Segmental artery occlusion can be achieved with either micro coils, or vascular plugs. A maximum number of seven SAs is currently recommended to be occluded in the same session, and a minimum interval of 5 days should be awaited between either two MIS2ACE sessions or between MIS2ACE and the final repair. Adjuvant side-effects of MIS2ACE are the reduction in segmental back-bleeding during open repair leading to harmful steal phenomenon and the reduction of the incidence of type II endoleaks in endovascular repair. Current contraindications for MIS2ACE are emergency cases, hostile anatomy, and a shaggy aorta. Other neuroprotective adjuncts such as cerebrospinal fluid (CSF) drainage, permissive hypertension, motor-evoked potentials (MEP)/somato-sensory evoked potentials (SSEP) and monitoring of paraspinous muscle oxygenation by near-infrared spectroscopy should also be applied independent of prior MIS2ACE procedure.

The impact of postoperative cerebrospinal fluid drainage on neurological improvement following thoracic aortic and thoracoabdominal aortic surgery

Background

Various preventive measures and treatment methods exist to prevent paraplegia during thoracic aortic surgery. Postoperative cerebrospinal fluid drainage (CSFD) is one of the treatment options when paraplegia occurs. This study aimed to evaluate the neurological efficacy of postoperative CSFD in patients undergoing thoracic aortic and thoracoabdominal aortic surgery.

Methods

We analyzed perioperative data from 85 patients who underwent perioperative CSFD for thoracic and thoracoabdominal aortic surgery between January 2006 and December 2022, focusing on neurological changes. A total of 61 patients (72%) received preoperative CSFD, and 24 patients (28%) received postoperative CSFD. Perioperative neurological data were analyzed with a focus on perioperative changes.

Results

In the postoperative CSFD group, the manual muscle test (MMT) score before CSFD was 0.8, that just after CSFD was 2.4, and that at discharge was 3.0. Therefore, postoperative CSFD improved MMT scores compared with preoperative CSFD. The mean time between surgery completion and postoperative CSFD implantation was 9.8 hours. However, 6 (25%) of the patients who developed postoperative paraplegia and underwent early postoperative CSFD remained paraplegic without any improvement. In the preoperative CSFD group, there was only one case (2%) of postoperative paraplegia.

Conclusions

Postoperative CSFD improved the neurological prognosis of individuals undergoing thoracic aortic and thoracoabdominal aortic surgery. However, 25% of the patients remained paraplegic despite postoperative CSFD.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair

OBJECTIVES

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy.

METHODS

From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n = 77, in 2015-2020), subjected to similar TAAA repair without 3D printing.

RESULTS

A total of 38 patients (58.6 ± 13.2 years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7 ± 55.5 minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0 ± 83.9 minutes, significantly longer than the 3D-printing group (P < .001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively.

CONCLUSIONS

Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

Paraplegia as a Rare Clinical Presentation of Relapsed Acute Myeloid Leukemia

Myeloid sarcoma, also known as granulocytic sarcoma or chloroma, is an extra-medullary accumulation of malignant myeloid blast cells, leading to a solid tumor formation. Herein, we report a rare presentation of a case with acute myeloid leukemia (AML), whose disease relapse was clinically evident as acute flaccid paraplegia with a certain sensory level. On thoracic spine magnetic resonance imaging (MRI), an epidural mass compressing the spinal cord at the level of the thoracic spine segment 4 (T4) was found. The mass histology confirmed the diagnosis of myeloid sarcoma.

Spinal decompression and stabilisation in a cat with lumbar vertebral pathological fracture and subluxation, following discospondylitis and spinal epidural empyema

Case series summary

A 1-year-old castrated male Maine Coon cat was referred because of a 1-week history of progressive spastic non-ambulatory paraparesis. An MRI examination of the thoracolumbar spine showed multiple lytic lesions, with the most aggressive one centred on the adjacent endplates of L1-L2 and its associated disc. Ventral new bone formation, L1 vertebral body shortening and mild dorsal displacement of the caudal aspect of L1 were noted. Contrast enhancement of both paravertebral soft tissue and extradural lesion was present. These findings were compatible with L1-L2 discospondylitis (DS), spinal epidural empyema (SEE), with secondary L1 pathological vertebral fracture, subluxation and spinal cord compression. CT of the thoracolumbar spine, abdomen and thorax confirmed these findings. The patient deteriorated to paraplegia with absent nociception, despite initial medical therapy. A right-sided L1-L2 hemilaminectomy and spinal decompression were then performed, followed by application of a unilateral construct comprising four smooth arthrodesis wires and polymethylmethacrylate (PMMA). Staphylococcus aureus was isolated from both epidural material, intraoperatively sampled and blood culture. Antibiotic therapy was continued for 6 weeks, based on susceptibility results. The outcome was excellent, with a gradual improvement and complete neurological recovery at the 8-week postoperative check. Repeated spinal radiographs showed an intact apparatus and marked signs of vertebral fusion. At the 14-month follow-up examination, the cat remained free of clinical signs.

Relevance and novel information

To the authors' knowledge, this is the first case report of SEE and DS in a cat that required surgical stabilisation. The outcome was still optimal, despite the rapid neurological deterioration.

Surgical management of a recurrent hydatid cyst in the thoracic spine of a postpartum patient with paraplegia: a rare case report and literature review

Background

Hydatid disease is a health problem caused by Echinococcus granulosis. Spinal hydatidosis is relatively uncommon when compared to hydatid disease of visceral organs, such as the liver.

Case Description

This report details the case of a 26-year-old female who presented acutely with incomplete paraplegia following delivery via cesarean section. She was previously treated for visceral and thoracic spine hydatid cyst disease. On magnetic resonance imaging (MRI), a cystic lesion suggestive of hydatid cyst disease was identified as causing severe cord compression, mainly at T7, raising suspicions of recurrence. Emergency decompression of the thoracic spinal cord via costotransversectomy was performed, as well as the removal of a hydatid cyst and instrumentation from T3-T10. Histopathology findings were consistent with a parasitic infection, specifically Echinococcus granulosis. The patient was administered albendazole for treatment and subsequently had full neurological recovery at the final follow-up.

Conclusions

Diagnosis and treatment of spinal hydatid disease is challenging. Surgical excision of the cyst for neural decompression and pathological identification of the cyst is the initial treatment of choice, alongside albendazole chemotherapy. In this review, we have analyzed spine cases reported in the literature and present the surgical approach applied to our case, which was the first reported case of spine hydatid cyst disease following delivery and recurrence. Uneventful surgery, avoiding cyst rupture, and treatment with antiparasitic medication are the mainstays of spine hydatid cyst management and avoidance of recurrence.

A Case Report of Klippel-Feil Syndrome Presenting as Tetraplegia

Cervical spine assessment is an important step in patients who sustained trauma. Klippel-Feil syndrome (KFS) is a complex syndrome with an abnormal fusion of cervical vertebrae at C2 and C3, which is caused by a failure in the division or normal segmentation of the cervical spine vertebrae in early fetal development. This condition leads to a characteristic appearance of a short neck, low hairline, facial asymmetry, and limited neck mobility. People with congenital defects like KFS are more prone to cervical spine injury. KFS is a relatively rare disease. Trivial trauma can lead to neurologic symptoms in such individuals. We present a 32-year-old male, with an alleged history of falls from height with traumatic injury to his head and spine. Following the event, he was unable to move all four limbs. The patient's short neck was noted. Magnetic resonance imaging (MRI) of the spine revealed multilevel fusion of four cervical vertebrae (C3-C7) with a single fused spine which is highly uncommon. Myelopathy secondary to C3-C4 disk protrusion is also seen. The patient was diagnosed with KFS and managed conservatively. The abnormal fusion in KFS predisposes to neurologic injury owing to altered biomechanics of the spine leading to hypermobility of the adjacent normal spine, spondylolisthesis, and stenosis, thereby increasing the likelihood of injuries. Screening and identification of KFS in young children are essential as counseling for lesser strenuous activity might avoid neurological injury and promote better neurological outcomes in the future.

Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: A systematic review

OBJECTIVES

While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia (SCI).

METHODS

In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed.

RESULTS

A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor evoked potentials (MEP), while 15 analysed somatosensory evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy (NIRS) during open TAAA repair.

CONCLUSIONS

Current literature suggest that rates of postoperative SCI can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair.

Complete Intradural Interbody Cage Migration in Lumbar Spine Surgery: A Case Report and Literature Review

Background: Spinal fusion is a common surgery, in which vertebrae are fused to restore spinal stability and eliminate pain during movement. The use of an interbody cage facilitates spinal fusion. However, complete cage migration into the dura matter rarely occurs and can be challenging to manage. Case Presentation: A 44-year-old man presented at our spine center with a history of incomplete paraplegia and cauda equina syndrome that had lasted for 2 years and 4 months. This condition developed after he underwent six lumbar spine surgeries to address lower back pain and right-sided sciatica. A structural allograft kidney-shaped cage was found completely within the dura at the level of the L3 vertebra. Durotomy, cage retrieval, and pedicle screw fixation from the L2 to L4 vertebrae were performed. Numbness in both lower limbs markedly decreased within several days of the operation. After four months following the progressive physical therapy, the patient could partially control both urination and defecation. Five months postoperatively, he could stand with slight assistance. Conclusions: Complete intradural cage migration is a rare and serious complication. To the best of our knowledge, this is the first reported case with such a condition in the literature. Even if treatment is delayed, surgical intervention may salvage the remaining neurologic function and may even lead to partial recovery.

Recovery of Spinal Walking in Paraplegic Dogs Using Physiotherapy and Supportive Devices to Maintain the Standing Position

Paraplegic patients have always been ideal candidates for physiotherapy due to their body's inability to recover on its own. Regardless of the cause that led to the onset of paraplegia (traumatic or degenerative), physiotherapy helps these patients with devices and methods designed to restore the proper functioning of their motility, as well as their quality of life. A total of 60 paraplegic dogs without deep pain in the hindlimbs caused by intervertebral disc extrusion or thoracolumbar fractures underwent physiotherapy sessions: manual therapy (massage), electrostimulation (10-20 min with possible repetition on the same day), ultrasound therapy, laser therapy, hydrotherapy, and assisted gait in supportive devices or on treadmills to stimulate and relearn walking, which was the main focus of the study. To maintain the standing position over time, we developed different devices adapted for each patient depending on the degree of damage and the possible associated pathologies: harnesses, trolleys, straps, exercise rollers, balancing platforms and mattresses, physio balls and rollers for recovery of proprioception. The main objective of our study was to demonstrate that physiotherapy and assisted gait in supportive devices to maintain the standing position may help paraplegic dogs to develop spinal walking. Concurrent pathologies (skin wounds, urinary infections, etc.) were managed concomitantly. Recovery of SW was evaluated by progression in regaining the reflectivity, nociception, gait score, and quality of life. After 125 to 320 physiotherapy sessions (25 to 64 weeks), 35 dogs (58.33%) developed spinal walking and were able to walk without falling or falling only sometimes in the case of a quick look (gait score 11.6 ± 1.57, with 14 considered normal), with a lack of coordination between the thoracic and pelvic limbs or difficulties in turning, especially when changing direction, but with the recovery of the quadrupedal position in less than 30 s. The majority of dogs recovering SW were of small size, with a median weight of 6.83 kg (range: 1.5-15.7), mixed breed (n = 9; 25.71%), Teckel (n = 4; 11.43%), Bichon (n = 5; 14.28%), Pekingese (n = 4; 11.43%), and Caniche (n = 2; 5.71%), while those who did not recover SW were larger in size, 15.59 kg (range: 5.5-45.2), and mixed breed (n = 16; 64%).

Retained lumbar intradural bullet fragment with neurological recovery after delayed removal of bullet: Case report and literature review

Civilian gunshot wound (GSW) to the spine is expected to increase in our environment due to the recent surge in violence and firearm attacks in the society either by herdsmen, bandits, unknown gunmen, or from exchange of gun fire with security personnel in response to insecurity issues. The management of GSW in the spine remains controversial, with no clear recommendations for surgical intervention by spine surgeons. In light of this, we report a case of civilian GSW to the lumbar spine in a 47-year-old female with resultant immediate paraplegia. Neuroradiological studies revealed a large bullet lodged in the left L2/3 spinal canal. There was a 4-week wait for consent for surgery to be obtained, with no improvement in motor function during the period. She underwent laminectomy and duratomy with removal of the bullet. Motor function returned 3 weeks after the surgery, and she was discharged home 8 weeks after the surgery, actively mobilizing on a Zimmer frame. The case report demonstrates the beneficial role of surgical intervention in properly selected patients, with resultant satisfactory functional neurological recovery.

Post-partum paraplegia following spinal anaesthesia: a report of two rare cases

Pregnancy and lumbar puncture are rare instances that can precipitate sudden onset paraplegia in patients with otherwise slow-growing intradural tumours. Surgeons and anaesthesiologists should be aware of the etiological factors leading to pregnancy- and delivery-related rapid tumour growth and its complications. Lumbar puncture-related complications leading to acute precipitation of neurological symptoms must be addressed promptly for favourable outcome in such patients. We describe the report of two patients who developed acute onset paraparesis after spinal anaesthesia for caesarean section. Both were found to be having undiagnosed spinal tumours and managed surgically. We recommend urgent MRI in cases of acute onset non-resolving paraparesis in the peripartum period, for timely diagnosis and management of this rare clinical entity.

Improved pulmonary function is associated with reduced inflammation after hybrid whole-body exercise training in persons with spinal cord injury

NEW FINDINGS

What is the central question of this study? Does 12 weeks of functional electrical stimulation (FES) rowing exercise training lead to suppressed systemic inflammation and an improvement in pulmonary function in persons with sub-acute spinal cord injury (SCI)? What is the main finding and its importance? Twelve weeks of FES rowing exercise improves pulmonary function and the magnitude of improvement is associated with reductions in inflammatory biomarkers. Thus, interventions targeting inflammation may lead to better pulmonary outcomes for person with sub-acute SCI.

ABSTRACT

The current study was designed to test the hypotheses that (1) reducing systemic inflammation via a 12-week functional electrical stimulation rowing exercise training (FESRT) prescription results in augmented pulmonary function, and (2) the magnitude of improvement in pulmonary function is inversely associated with the magnitude of systemic inflammation suppression in persons with sub-acute (≤2 years) spinal cord injury (SCI). We conducted a retrospective analysis of a randomized controlled trial (NCT#02139436). Twenty-one participants were enrolled (standard of care (SOC; n = 9) or FESRT (n = 12)). The exercise prescription was three sessions/week at 70-85% of peak heart rate. A two-way analysis of covariance and regression analysis was used to assess group differences and associations between pulmonary function, log transformed high-sensitivity C-reactive protein (hsCRPlog ) and white blood cell count (WBC). Following FESRT, clinically significant improvements in forced expiratory volume in 1 s (FEV1 ; 0.25 (0.08-0.43) vs. -0.06 (-0.26 to 0.15) litres) and forced vital capacity (0.22 (0.04-0.39) vs. 0.08 (-0.29 to 0.12) litres) were noted and systemic WBC (-1.45 (-2.48 to -0.50) vs. 0.41 (-0.74 to 1.56) μl) levels were suppressed compared to SOC (mean change (95% confidence interval); P < 0.05). Additionally, both ΔhsCRPlog and ΔWBC were predictors of ΔFEV1 (r2  = 0.89 and 0.43, respectively; P < 0.05). Twelve weeks of FESRT improves pulmonary function and reduces WBC in persons with sub-acute SCI. The potency of FESRT to augment pulmonary function may depend on adequate suppression of systemic inflammation.

Spinal Cord Injury and Complications Related to Neuraxial Anaesthesia Procedures: A Systematic Review

The use of neuraxial procedures, such as spinal and epidural anaesthesia, has been linked to some possible complications. In addition, spinal cord injuries due to anaesthetic practice (Anaes-SCI) are rare events but remain a significant concern for many patients undergoing surgery. This systematic review aimed to identify high-risk patients summarise the causes, consequences, and management/recommendations of SCI due to neuraxial techniques in anaesthesia. A comprehensive search of the literature was conducted in accordance with Cochrane recommendations, and inclusion criteria were applied to identify relevant studies. From the 384 studies initially screened, 31 were critically appraised, and the data were extracted and analysed. The results of this review suggest that the main risk factors reported were extremes of age, obesity, and diabetes. Anaes-SCI was reported as a consequence of hematoma, trauma, abscess, ischemia, and infarction, among others. As a result, mainly motor deficits, sensory loss, and pain were reported. Many authors reported delayed treatments to resolve Anaes-SCI. Despite the potential complications, neuraxial techniques are still one of the best options for opioid-sparing pain prevention and management, reducing patients' morbidity, improving outcomes, reducing the length of hospital stay, and pain chronification, with a consequent economic benefit. The main findings of this review highlight the importance of careful patient management and close monitoring during neuraxial anaesthesia procedures to minimise the risk of spinal cord injury and complications.

Single-session repair of multiple pressure ulcers in non-ambulatory patients

OBJECTIVE

Pressure ulcers (PUs) are highly prevalent and challenging wounds. In this study, patients with either tetraplegia or paraplegia, all of whom had multiple grade 4 PUs and who underwent single-session surgical treatment were included. In order to increase the mobility of the musculocutaneous flap, the gluteus maximus muscle, which cannot be used by immobile patients, was detached and inserted into the flap.

METHOD

This was a retrospective case series and all PUs were reconstructed within the same surgical session.

RESULTS

A total of nine patients participated in the study, all of whom were male. Mean age was 33 years (range: 20-42 years). Mean follow-up period was 14.3 months (range: 9-24 months). All patients had a successful single-session repair of all PUs. Total or partial flap losses were not observed. Mean and total number of reconstructed PUs were 2.55 and 23, respectively. The mean area of reconstructed open wounds per patient was 174.6cm² and the mean operation duration was 253 minutes. The level of blood loss was acceptable as the decrease in haemoglobin levels was not more than 2g/dl for each patient.

CONCLUSION

Multiple PUs can be repaired in one session using gluteus maximus musculocutaneous flaps in immobile patients. Based on the fact that the gluteus maximus is an essential muscle for ambulation, our approach can only be used in the treatment of patients with irreversible paraplegia or tetraplegia. When all prerequsities are met, the amount of blood loss and operation duration are acceptable, and returning the patient to a wound-free state can be achieved more quickly compared to multi-session repairs. Air-fluidised beds are vital tools for accomplishing single session repairs of multiple PUs. The data shows that the approach is safe and can be used in patients with multiple PUs.

The risk of malnutrition in patients with spinal cord injury during inpatient rehabilitation-A longitudinal cohort study

Background and aim

Patients with spinal cord injury (SCI) show an increased risk of malnutrition. Studies found that about 50% of patients with a recent SCI are affected by malnutrition when they enter a rehabilitation institution. However, there is a lack of data during the course and at discharge of initial rehabilitation as well as missing knowledge about the factors promoting such a risk. The aim of this study was to assess the risk of malnutrition in individuals with SCI 3 months post injury and at the end of inpatient rehabilitation and to identify factors associated with a high risk of malnutrition.

Methods

Retrospective, monocentric, longitudinal cohort study, using the data set of the Swiss Spinal Cord Injury Cohort Study and additional data from the patients' medical records. Individuals with SCI were assessed for the risk of malnutrition using the Spinal Nutrition Screening Tool 3 months post injury and at discharge from initial inpatient rehabilitation. Odds ratios (OR) for potential risk parameters were calculated.

Results

Of the 252 participants included, 62% were at risk for malnutrition 3 months post injury and 40% at discharge (p = 0.000). Moderate to high risk of malnutrition was found regardless of age and BMI. The highest odds for an increased risk at 3 months post injury was identified in ventilator-dependent persons (OR 10.2). At discharge from inpatient rehabilitation, pressure injury (OR 16.3) was the most prominent risk factor.

Conclusion

In the population with SCI the risk of malnutrition is widespread during inpatient rehabilitation, but also at discharge. Ventilated persons and persons with pressure injuries are clear risk groups and need special attention. Based on these findings and the known negative impact of malnutrition on clinical outcomes, the awareness of malnutrition should be increased in the population with SCI. Therefore, a regular and standardized screening of the malnutrition risk is highly recommended.

Thoracic Spinal Intradural Arachnoid Cyst With a Fulminant Course

Background: Spinal arachnoid cysts are rarely occurring benign cerebrospinal fluid-containing lesions that can occur anywhere along the spinal axis but are principally seen in the thoracic spine. They occur either ventrally or dorsally and can be extradural, intradural extramedullary, or intramedullary. They may be asymptomatic or can present with insidious pain and neurologic symptoms related to spinal cord and/or nerve root compression. Case Report: A 49-year-old male developed sudden midback pain with rapid progression to gait instability, urinary retention, and paraplegia within 10 hours. His presentation for neurosurgical care was delayed because of lack of funds and unfavorable insurance policies. At presentation 3 months after the onset of symptoms, magnetic resonance imaging of his spine showed a ventrolateral intradural extramedullary cystic lesion at T5-T6 with severe cord compression. He underwent T5-T6 and T6-T7 laminectomies with a limited left sixth rib costotransversectomy for microsurgical resection of the cyst. Postoperatively, the patient reported improvement in bladder and bowel control, but his paraplegia persisted. Conclusion: Arachnoid cysts are mostly benign lesions; however, they may have disastrous outcomes if not promptly addressed with the necessary urgency when symptoms are progressive, as in our patient.

Fatal Case of Giant Chondrosarcoma of Rib with Paraplegia: A Case Report

Introduction

Chondrosarcoma of rib encroaching spine and subsequently leading to paraplegia has never been reported in the literature. Association of paraplegia can often lead to misdiagnosis with a common disease like breast cancer or Potts spine causing a significant delay in treatment.

Case Report

We describe a case of a 45-year-old male with chondrosarcoma of rib with paraplegia who was misdiagnosed initially as Pott's spine and was started empirically on anti-tubercular treatment for paraplegia and chest wall mass. Further work up at tertiary care center including detailed imaging and biopsy revealed features of chondrosarcoma. However, before any definitive treatment could be done; the patient passed away.

Conclusion

Empirical treatment of paraplegia with chest wall mass for more common diseases like tuberculosis are often initiated without obtaining appropriate radiological and tissue diagnosis. This can lead to a delay in diagnosis and initiation of treatment.

Ultrasound-Guided Percutaneous Radiofrequency Thermal Neuroablation for the Treatment of Adductor and Rectus Femoris Spasticity

Spasticity is a very frequent complication of spinal cord injury (SCI) that can limit activities of daily living, reduce the quality of life, and augment caregiver burden. This problem has many treatment options that should be selected according to the clinical and functional scenario.  This case study presents a 60-year-old female patient with complete spastic paraplegia after a spinal stroke. Spasticity interfered with activities of daily living, mainly with intermittent catheterization and transfers, and botulinum toxin injections failed to efficiently treat this issue. It was decided to perform an ultrasound-guided radiofrequency thermal ablation of the anterior and posterior branches of the obturator nerve and motor branches to the rectus femoris of the femoral nerve to treat the adductors and rectus femoris spasticity. One year after the radiofrequency treatment, the patient showed considerably reduced spasticity, allowing her caregiver to do transfers and easier intermittent urinary catheterizations. Nerve radiofrequency thermal ablation has the potential to be an effective therapy in lower limb spasticity, with long-lasting effects.

Frequency and Causes of Traumatic and Non-traumatic Spinal Injury Reported at Two Major Tertiary Care Hospitals of Khyber Pakhtunkhwa

Introduction Spinal cord injury, due to traumatic or non-traumatic causes, is a medically challenging and life-disrupting condition. The injury disrupts neural signaling and is a medical emergency requiring immediate treatment that can reduce long-term effects like paralysis or partial disability of the body. It has costly consequences both for individuals and families because it causes not only physical disability but dependency on others. The main objectives of the study were to determine the frequency of spinal injuries, their nature, and their causes. Materials and methods A descriptive exploratory study was conducted in the neurosurgery wards of two major hospitals of Peshawar, Lady Reading Hospital and Hayatabad Medical Complex. Necessary permission was taken from the administration of both hospitals before starting data collection. The duration of the study was three months, from October to December 2014. A total of 768 patients were retrieved from the ward records for 2013, from which a 50% random sample was taken (384 patients) while incomplete patient records were excluded. The data were transferred and recorded on a pre-constructed proforma covering all the required variables of the study. Finally, the data were transferred to SPSS 15 (SPSS Inc., Chicago) for analysis of descriptive statistics. In addition, comparisons were done by gender, hospitals, types of injuries, and causes of injuries. The chi-square test was used to compare groups for significant differences in frequencies, keeping p ≤0.05 as significant. Results Major factors for spinal cord injury were traumatic and non-traumatic. This study revealed that out of the total patients, 35% faced trauma as a cause of spinal disorder out of which 42%, 29%, and 21% were sudden falls, road traffic accidents (RTAs), and weight lifting, respectively. While non-traumatic causes were 52% mostly due to congenital anomalies (24%), stenosis (23%), and tumor (12%). Levels most commonly involved were lumbar (42.3%) followed by patients involving multiple levels (32.52%), L5-S1 (20.87%), thoracic (2.42%), and cervical (1.92%). Conclusions The traumatic injury was the leading cause of spinal cord injury in the present study where RTAs and falls contributed the most. Congenital abnormalities and spinal cord stenosis were more frequent among non-traumatic spinal cord injuries. The surgical approach was the only way of management practiced for spinal cord injuries in both of the tertiary care hospitals.

One-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment TB

To evaluate the clinical efficacy of 1-stage anterior focus debridement, interbody bone graft, and anterior instrumentation and fusion in the treatment of short segment thoracic tuberculosis with paraplegia or incomplete paralysis. A total of 16 adult patients with short segment thoracic spinal thoracic tuberculosis who underwent surgery were enrolled in this retrospective study. All patients received anterior focus debridement, interbody bone graft and anterior instrumentation and fusion. All patients were followed up for 24 to 48 months. Clinical manifestations, laboratory examinations, neurological symptoms, bone fusion and imaging results were analyzed. All patients successfully underwent operations. The symptoms of chest and back pain were alleviated and even disappeared during postoperative 1 to 6 months. There was no recurrence. All patients got bony spinal fusion within postoperative 4 to 8 months assessed by spinal X-ray film. The levels of erythrocyte sedimentation rate and C-reactive protein were significantly decreased from 72.6 ± 27.5 mm/h and 75.7 ± 25.9 mg/L to 15.9 ± 4.6mm/h and 4.7 ± 2.0mg/L at the final follow-up, respectively (P < .05). The thoracic kyphosis angle was also notably decreased from 15.0 ± 3.4° to 9.1 ± 1.9° after operation(P < .05). During the follow-up, the symptom of paraplegia or incomplete paralysis was significantly improved. Neurologic status in all patients was also improved to some extent. The combination of 1-stage anterior focus debridement, interbody bone graft and anterior instrumentation and fusion is an effective and feasible treatment method for short segmental thoracic tuberculosis with paraplegia or incomplete paralysis.

A Case of Paraplegia Treated with Cerebrospinal Fluid Drainage and Permissive Hypertension after Graft Replacement of the Ascending Aorta and the Total Aortic Arch for Acute Aortic Dissection Stanford Type A

Paraplegia after an operation for acute aortic dissection Stanford type A (AADA) is fairly uncommon, and there is no consensus about optimal treatment. We present a case in which cerebrospinal fluid drainage (CSFD) and permissive hypertension were used for treatment of paraplegia. When the patient showed complete bilateral paraplegia after operation for AADA, we immediately began CSFD and maintained mean arterial blood pressure at over 90 mmHg. His neurological deficit gradually recovered, and he was eventually able to walk without support. The combination of CSFD and permissive hypertension could be a first-line emergent treatment for postoperative paraplegia after AADA surgery.

Rehabilitation Towards Functional Independence in a Patient With Intertrochanteric Fracture and Paraplegia: A Case Report

Traumatic spinal cord injury (SCI) causes significant neurological deficits that adversely affect the quality of life of patients and caregivers. Patients with SCI present with the symptoms of weakness and loss of sensations in the limbs. Motor deficits may occur in the form of paraplegia, hemiplegia, or quadriplegia. Patients remain immobilized for a prolonged period which may lead to complications like muscle wasting, atrophy, joint stiffness, contractures, bed sores, and osteoporosis. Patients are prone to fractures owing to osteoporosis. The fractures may occur even due to trivial trauma. Our case report presents the case of a 45-year-old male patient who is already diagnosed with paraplegia having a history of SCI one-and-a-half years ago. He has recent history of intertrochanteric (IT) fracture that occurs during the transfer from bed to wheelchair. Admitted to the hospital with a complaint of a popping sound along with low back pain. Further investigation and management were started.

Evaluation of Cardiovascular Autonomic Function during Inpatient Rehabilitation following Traumatic Spinal Cord Injury

Assessment of the degree of impaired autonomic nervous system (ANS) function is not part of routine clinical practice during inpatient rehabilitation following traumatic spinal cord injury (SCI). The goal of this investigation was to determine the utility of the International Standards for Neurologic Classification of SCI (ISNCSCI) and the recently revised International Standards to document remaining Autonomic Function after SCI (ISAFSCI) in documenting cardiovascular ANS impairment during inpatient rehabilitation following traumatic SCI. Beat-to-beat recording of supine heart rate (HR) and blood pressure (BP) were collected at the bedside for estimation of total cardiovascular ISAFSCI score, cardio-vagal modulation (i.e., high frequency HR variability [HFHRV]) and sympathetic vasomotor regulation (i.e., Mayer wave component of systolic BP [SBPmayer]). A total of 41 participants completed baseline testing, which was conducted 11 ± 5 days from the admission ISNCSCI examination. There were no differences in supine HR or BP based on the ISNCSCI or ISAFSCI assessments. The HFHRV was generally lower with more distal lesions (r2 = 0.15; p = 0.01), and SBPmayer was significantly lower in those with American Spinal Injury Association Impairment Scale (AIS) A compared with AIS B, C, D (Cohen's d = -1.4; p < 0.001). There were no significant differences in HFHRV or SBPmayer in patients with or without ISAFSCI evidence of cardiovascular ANS impairment. These preliminary data suggest that neither the ISNCSCI nor the ISAFSCI are sensitive to changes in ANS cardiovascular function following traumatic SCI. Bedside assessment of HR and BP variabilities may provide insight, but are not readily available in the clinical setting. Further research is required to evaluate methods that accurately assess the degree of ANS impairment following traumatic SCI.